UNINSURED ADULT WORKING-AGE POPULATION IN TARRANT COUNTY: ACCESS, COST OF CARE, AND HEALTH--HISPANIC IMMIGRANTS. Courtney M. Queen, B.B.S.

UNINSURED ADULT WORKING-AGE POPULATION IN TARRANT COUNTY: ACCESS, COST OF CARE, AND HEALTH--HISPANIC IMMIGRANTS Courtney M. Queen, B.B.S. Thesis Prepared for the Degree of MASTER OF SCIENCE UNIVERSITY OF NORTH TEXAS August 2004 APPROVED: Susan Eve, Major Professor Erma Lawson, Minor Professor Daniel G. Rodeheaver, Committee Member David Williamson, Chair of the Department of Sociology David W. Hartman, Dean of the School of Community Service Sandra L. Terrell, Dean of the Robert B. Toulouse School of Graduate Studies

Queen, Courtney M. Uninsured Adult Working-Age Population in Tarrant County: Access, Cost of Care, and Health--Hispanic Immigrants. Master of Science (Sociology), August 2004, 132 pp., 13 tables, references, 87 titles. This study uses secondary survey data collected from a sample population of clients from JPS Health Network in Tarrant County, Texas from July-August, 2000. Respondents for this study represents a group of working-age Hispanic immigrant adults, N=379. Andersen s Behavioral Model for Vulnerable Populations is used to as the theoretical framework. Bivariate crosstabulation revealed significant relationships for dependent variables: problems getting needed healthcare, doctor visits, emergency room visits, overnight in the hospital, and obtaining prescription medication. Findings confirm that lack of coverage, competing needs, and difficulties in the health care system are significant in access health care. Subsequent implications and policy recommendations suggests the inevitability of short and long term health consequences unless changes are made to policies and programs.

Copyright 2004 by Courtney M. Queen ii

TABLE OF CONTENTS LIST OF TABLES...iv Chapter 1. INTRODUCTION... 1 Theoretical Framework Research Questions Hypotheses Literature Review Summary 2. METHODOLOGY... 24 Population and Sample Research Design Analyses Operational Measures of the Dependent and Independent Variables Frequencies of the Independent Variables 3. FINDINGS... 47 Results from the Bivariate Analyses Summary of the Findings from the Bivariate Analyses 4. SUMMARY... 71 Summary of Findings Policy Recommendations Implications Summary APPENDIX A... 95 APPENDIX B...107 APPENDIX C...113 APPENDIX D...115 APPENDIX E...120 BIBLIOGRAPHY...125 iii

LIST OF TABLES Page 1. The Behavioral Model for Vulnerable Populations applied to Hispanic immigrants within the JPS Health Network, Tarrant County, Texas... 3 2. Frequencies of the Dependent Variables... 35 3. Frequencies of the Predisposing, Traditional Independent Variables... 42 4. Frequencies of the Predisposing, Vulnerable Independent Variables... 42 5. Frequencies of the Enabling, Traditional Variables... 43 6. Frequencies of the Enabling, Vulnerable Variables, and Need... 45 7. Bivariate Analyses of Predictor Variables with Problem Getting Needed Healthcare in the last 12 Months... 51 8. Bivariate Analyses of Predictor Variables with Seen in ED in the Last 12 Months... 56 9. Bivariate Analyses of Predictor Variables with Overnight in Hospital... 59 10. Bivariate Analyses of Predictor Variables with Doctor Visits, Excluding ED Visits... 62 11. Bivariate Analyses of Predictor Variables with Wanted a Prescription Med, Could t Get... 66 12. Significant Predictors of Access to Healthcare... 74 13. Accepted and Rejected Hypotheses... 85 iv

CHAPTER 1 INTRODUCTION, THEORETICAL FRAMEWORK, RESEARCH QUESTIONS, HYPOTHESES, LITERATURE REVIEW Introduction Texas has one of the highest rates of medically uninsured in the United States. More than one-tenth of the nation s uninsured live in Texas. One in five Texans lack health insurance. The distribution of uninsured in Texas is concentrated in only ten counties. Over one-third of the uninsured live in Harris, Dallas, and Bexar counties. Tarrant County accounts for 349,556 (6.9% percent) of the uninsured in Texas (Texas Department, 2002). Since the number of uninsured increased from 3.6 million to 4.5 million in a decade (Texas Department, 2002), one can only expect that the plight of the uninsured will continue. As populations become more diverse, and more Texans are uninsured, vulnerable populations are disadvantaged. The Hispanic population both in Texas and in the United States are disproportionately placed in vulnerable positions first because of their minority status, and then again through the lack of access to health care. Overall, Hispanic, refugee, and immigrant populations fare poorly in both potential and realized access to medical care (Urrutia-Rojas & Aday, 1991). Hispanic immigrants receive fewer services than native-born citizens and are more likely to lack health coverage. The low-income immigrant population is twice as likely to be uninsured as low-income, non-immigrant citizens (Kaiser, 2000a; Doty, 2003). Lack of equity in distribution of access to health care is a growing concern, particularly among specific, vulnerable 1

populations. Barriers impeding and preventing access to health care include social and structural barriers such as language, discrimination, lack of understanding, and fear of deportation. These barriers to health care limit access and raise concerns for the health of the Hispanic immigrant population, including both children and adults. Changes to alleviate the barriers that impede access to health care need to occur in the health care system to ensure that the health care needs of the Hispanic immigrant population are met. Using data collected from a sample population of clients of the John Peter Smith safety-net health care network, Tarrant County, Texas, by Eve, Koelln, Trevino, Rojas, and Baumer (2000), this study seeks first to develop a profile of the uninsured Hispanic immigrant population in Tarrant County, Texas, and second, determine the social and structural barriers impeding access to appropriate health care. This study will assess the social, economic, and demographic characteristics of the sample population so as to determine how these variables affect the use of health services in the past year. Objectives of the Study. This study has three objectives. The first objective is to explain access to health care by Hispanic immigrants, within a safety-net health care system. The second objective is to highlight relevant policy variables that are determinants of use of health care services and that may be useful to improve health care seeking behaviors of Hispanic immigrants. The third objective is to add to the literature and theoretical synthesis of Hispanic immigrants access to health care. 2

Theoretical Framework The conceptual framework for Uninsured Adult Working-age Population in Tarrant County: Access, Cost of Care, and Health--Hispanic Immigrants is the Behavioral Model for Vulnerable Populations (Gelberg, Andersen, and Leake, 2000). study. Theoretical Model. Table 1 illustrates the Behavioral Model for Vulnerable Populations used for this Table 1.. The Behavioral Model for Vulnerable Populations applied to Hispanic Immigrants within the JPS Health Network, Tarrant County, Texas. Predisposing Enabling Needs Health Behavior Traditional Variables Demographics Age Sex Marital Status Vulnerable Variables Social Structure Race/ethnicity Language Citizenship Birthplace Amount of time in U.S. Traditional Variables Financial Resources Employment status Insurance coverage JPS Connections Employer Spouse Medicare Medicaid insurance Usual source of care Vulnerable Variables Paid time off Paid sick time Accompanying person Interpreters Paperwork Transportation Competing needs for food, housing, clothing (Gelberg, Andersen, and Leake, 2000). Perception of Overall Health Use of Physician Services Use of Emergency department Overnight in Hospital Access to Prescription Medicines Lack of Access Predictors in the Behavioral Model for Vulnerable Populations are divided into two 3

categories: traditional and vulnerable domains. The traditional domain includes predisposing, enabling, and need variables that are general to the total U.S. population. The vulnerable domain includes variables that are specific to a particular vulnerable group. In the case of Hispanic immigrants, variables include language, immigration status, and acculturation (Gelberg, Andersen, and Leake, 2000). Need is measured according to perceived need and evaluated based on one s subjective interpretation of health status. Outcome in this study is measured by access of health services by patients in the JPS Health Network. Immigrant status is a social structural variable and vulnerable characteristic. In this thesis, I will assess the effects of the vulnerability and need for health care based on perceived health status and utilization of health services. Study Variables and Empirical Model. Table 1 represents the dependent and independent variables as they are tested and measured in relation to Hispanic immigrants within the JPS Health Network. Because this study involves secondary analysis, I am presenting the table with the actual variables I will use in the research above. In the literature review that follows, I will discuss the support found in the literature for each of these variables. Research Questions Listed below are the research questions for this study, Hispanic immigrants and access to health care within the John Peter Smith Health Network: 1. General. What are the influential factors for Hispanic immigrants access to health services in the JPS Health Network? 4

2. Resources. How do resources such as insurance coverage and having a usual source for care influence the Hispanic immigrants ability to obtain needed health care services, including prescription medication? 3. Competing Needs. How do competing needs of food, clothing, housing, and transportation influence one s ability to obtain needed health services and prescription medication? 4. Institutional Challenges. What is the role of structural barriers such as paperwork and interpretation services in accessing health services at JPS? 5. Need. How does perception of overall health relate to access of the JPS Health Network? 6. Vulnerability. What is the influence of demographic variables such as age, sex, and marital status on Hispanic immigrants ability to access JPS Health Network? 7. Immigration. What is the relationship between birth country, amount of years in the United States, and access to health care? Hypotheses Following are the twenty-four hypotheses representing the independent variables as they are measured against the five dependent variables. The five dependent variables are: 1) problems getting health care in the last twelve months; 2) doctor visits, excluding emergency department service in past twelve months; 3) emergency department visits in the last twelve months; 4) overnight stay in the hospital in the past twelve months; and, 5) wanted a prescription but could not get. 1. Age. Older adults will use health care more than younger adults. 5

2. Sex. Sex will be related to access to health care. Men will show greater access to health care than women. 3. Marital Status. Those who are married will show greater access to health care services than will those who are not married. 4. Speaks Spanish at home. Those who speak Spanish at home will show less access to health care services than those who do not speak Spanish in the home. 5. Speaks English at home. Those who speak English at home will show greater access to health care services than those who do not speak English at home. 6. Born in the United States. Those individuals born in the United States will show greater access to health care services than will foreign-born residents. 7. Years in the United States. Individuals who have been in the United States longer will show greater access to health care services than will individuals who have just recently come to the United States. 8. Paying job. Individuals with a paying job will show greater access to health care services due to coverage through work than will individuals without a paying job. 9. Coverage through JPS. Those with JPS Connections coverage will show greater utilization of health care than will those who do not have JPS coverage. 10. Coverage through work. Those with medical coverage through work will show greater access to health care than will those who do not have coverage through work. 11. Coverage through spouse s work. Those with medical coverage through their spouse s work will show greater access to health care than will those who do not 6

have coverage through their spouse s work. 12. Coverage through Medicare. Those with medical coverage through Medicare will show greater access to health care than those without Medicare coverage. 13. Coverage through Medicaid. Those with medical coverage through Medicaid will show greater access to health care than those who do not have Medicaid. 14. Did not have coverage in the last 12 months. Those without medical coverage will show less access to health care than those who did have medical coverage. 15. Has usual source for care. Those individuals with a usual source for care will not use ED and hospital services as often as those who do not, but they will have greater access to physicians and prescription medicines. 16. Gets paid time-off to go to Doctor. Individuals who get paid time-off to go to the doctor will show greater access to health care than individuals who do not get paid time-off. 17. Gets paid time-off when sick. Individuals who get paid time-off when sick will show greater use of health care than those who do not get paid time-off. 18. Put off going to doctor because accompanying person could not get off work. Individuals who do not have a person to accompany them will show less access to health care services than those who have someone to go with them. 19. Needed an interpreter in the last 12 months. Those who needed an interpreter in the last twelve months will show less access to health care than those who did not need an interpreter. 20. Problems getting an interpreter in the last 12 months. Those who found 7

difficulty obtaining assistance with language will access health care than those who have no difficulty with language. 21. Problems with paperwork. Those who found paperwork difficult will access health care less than those who had no problems with paperwork. 22. Competing needs for food, clothing, housing. Those with competing needs will show less access to the health care system. 23. Difficulty with transportation. Those without transportation will show less access to health care services than those with access to transportation. 24. Perception of overall health. Individuals with less than good perception of overall health will access the health care system less than those with greater perception of overall health. Literature Review This literature review cites relevant studies of Hispanic and Hispanic immigrants access to medical coverage. Studies presented in this literature review are evidence of national, state, county, and local level investigations. They are employed using the Behavioral Model for Vulnerable Populations (Gelberg, Andersen, and Leake, 2000). Topics useful for discussion include a profile of the population, citizenship status, language, issues of employment and income, health insurance coverage, employerbased coverage, the language barrier, and perceived health needs. Appendixes A through D provide tables of studies referenced and conducted. Profile. Immigrants constitute about twenty percent of the forty-four million uninsured in 8

the United States (Kaiser, 2000a). Health coverage varies across the United States. The immigrant and Hispanic populations are disproportionately represented at both the national and state levels, with the burden for the health of the community placed on illequipped public entities. Texas is among the states with the largest uninsured population, at fifty-six percent of the immigrant population. New York and California each have forty-six percent of their population uninsured. Only six percent of the immigrant population in Texas receives Medicaid benefits, while fifteen percent of the immigrant population in New York receives Medicaid benefits (Kaiser, 2003b). Government programs carry the burden of providing health services to those otherwise uninsured. Twelve percent of adults in all minority groups receive public assistance (Commonwealth, n.d.). In Texas, the Hispanic minority group represents fifty percent of the state s uninsured population, though immigrants constitute only one-third of the state s total population (Texas Department, 2002). California, Florida, New York, and Texas share the majority of the immigrant population. These states together have sixty-nine percent of all Hispanics and seventythree percent of all uninsured Hispanics. If these states did not have such high uninsured rates within the Hispanic populations, their rates for the uninsured would approach the national average. Of the total population of uninsured Hispanics, oneforth of the uninsured live in Texas, while one-third reside in California (Quinn, 2000). A significant proportion of the population is uninsured. The concern is that these individuals are at risk, despite the majority being employed. Working age, minority adults do not have health insurance, as public insurance programs such as programs for 9

children (CHIP) and the elderly (Medicare and Medicaid). Employers typically provide health coverage to working adults. Hispanics and immigrants tend to work for a sector of the economy that does not supply health coverage and benefits to workers. These types of positions also place minority workers in positions of vulnerability. Although a third of minority adults and only twenty-one percent of white adults are between the ages of 18 and 29 (Commonwealth, n.d.), these working-age adults constitute a population with jobs, living at poverty level and supporting a family--without health coverage. In addition, studies by the Commonwealth Fund reveal that over half of these minority families are living in households of more than three people. The same study also revealed that in addition to supporting families, minorities, including Hispanics, are living disproportionately on incomes of $15,000 or less (Commonwealth, n.d.). These characteristics represent the profile of Hispanic immigrants. Citizenship and Residency. The 1990 National Health Interview Survey Supplement on Family Research also employs the model for identifying predisposing, enabling, and need factors for accessing health care services. Results indicate that the duration of residence has a strong effect on health care utilization through socioeconomic status and access to insurance. These findings are also consistent with larger health implications (Ell and Castaneda, 1998). The Kaiser Commission on Medicaid and the Uninsured publish many studies on immigration status and access to health care. They have recently published findings stating that citizenship status and language contribute to disparities in access to the 10

health care system (Kaiser, 2003a). Controlling for citizenship status and immigrant status decreases the effect of race and ethnicity on access to healthcare (Kaiser, 2000a). The authors note that immigrants are overrepresented among uninsured populations (UCLA & Kaiser, 2000). Citizenship status (e.g. citizen, legal immigrant, or undocumented alien) plays a role in one s ability to obtain health coverage, including the ability to get a job that provides coverage or to obtain public funding like Medicaid or SCHIP (Kaiser, 2003a). The Texas Department of Insurance indicates that over half of those who are not citizens do not have health coverage. Nearly one-fifth of the total uninsured in Texas is non-citizens. Although many who fit into it category are non-citizens, this does not indicate that they are in the state illegally (2002). Another major barrier to insurance coverage mentioned by some uninsured participants was concern over immigration status. Many immigrants fear that signing up for insurance might create problems with immigration officials (Perry et. al., 2000). In another study citing the same fear, Ku and Frielich found undocumented aliens to have the greatest problems accessing the health care system. Many are unaware of the benefits available to them (2001). The Texas Department of Insurance recognizes that fear plays a role in limiting immigrants access to care. This is especially for children whose parents are afraid of deportation (Texas Department, 2002). At the same time, health institutions fear repercussions from government agencies. The same study by Ku and Freilich (2001) recognizes that health institutions many times still refuse service to undocumented aliens based on citizenship status, resulting in lack of access to care. Ku 11

and Freilich report that the public hospital systems in both Houston and Miami still do not provide locally subsidized health services unless a patient provides documentation of citizenship (2001). This is also true of counties in Texas. Lack of citizenship not only affects access to public benefits and care, but also job-based coverage. Most non-citizens are employed in positions that do not extend benefits to employees (Kaiser, 2003a; Kaiser, 2000d). Citizenship status and number of years in the country may prevent coverage through public funding such as Medicaid or SCHIP (UCLA & Kaiser, 2000). n-u.s.- born Hispanics are twice as likely as U.S.-born Hispanics to be uninsured. The discrepancy that exists across immigrant populations in that seventy-two percent of Hispanic immigrants lack coverage compared to twenty-eight percent of non-hispanic immigrants. Hispanic immigrants living in the U.S. fifteen years or more are twice as likely to be uninsured compared to other immigrant groups (Commonwealth, 2001a). Schur et. al. (2001) reports a strong inverse relationship between residence and health coverage. Close to three-fourths of Hispanics living in the U.S. for less than five years are uninsured. Language. Language barriers present a burden for many immigrants. Language differences present a problem for twenty-one percent of minority Americans receiving health care. Of those who do not speak English as a first language, twenty-six percent of Hispanic adults need an interpreter when seeking health care services (Commonwealth, n.d.). Previous studies found that those Hispanics who speak Spanish as the primary language 12

at home, report greater difficulties than those who speak English as the primary language. More than forty-three percent of Spanish-speaking Hispanics report problems communicating with or understanding their doctor, further impeding potential access to health care (Doty & Ives, 2002). The chance of not having health insurance is greater for both Spanish-speaking citizens and Spanish-speaking non-citizens. Seventy-five percent of non-citizen, Spanish-speaking adults lacks health coverage (Kaiser, 2003a). Once in the health care system, Hispanic immigrants experience a different kind of barrier when speaking with health care providers and practitioners. Communicating and speaking with health care providers and practitioners is difficult when doing so in one s non-native language. A significant number of studies address both language barriers and comprehension when trying to communicate health needs or instructions from their health care providers. Doty reports problems specific to Hispanics in a study in 2003. Hispanics do encounter greater difficulty in both understanding and comprehension than other ethnic groups. These problems are greatest among those who speak Spanish as their primary language (Kaiser, 2003a). These difficulties present great problems for those seeking health care. Hispanic immigrants are left without access to healthcare, even with health insurance. Many times those with health coverage forego necessary health care. Nearly half of the Spanish-speaking Hispanic population is without health insurance, and they experience problems communicating with their doctors (Perry et. al., 2000). This thereby supports previous claims that language is a mitigating factor not only in communicating with health care providers, but also as a barrier to coverage. 13

Access to health care is contingent upon the ability to access the health care system. Hispanic immigrants are not accessing the health care system at the same rates as other ethnic groups. Accommodating clients language needs is not only required by federal law, but also absolutely necessary to provide adequate care to the individual (Doty, 2003). Doty reports that an unmet need exists, and it is in the lack of trained, Spanish speaking medical interpreters (2003). Without these services, successful navigation of the health system is difficult (Families, 2001). Language barriers pose a problem when considering available literature and the necessity to read directions or instructions. Materials and other information about health insurance options are not always available in Spanish. In addition, written prescriptions also pose potential difficulties, as well as instructions from the physician (Perry et. al., 2000). Without Spanish-speaking health care providers, a very necessary element in treatment is missing. Overall, Hispanics are actually less likely to report good communication with their medical providers; non-citizens are more likely to report good communication with health care providers than citizens are less than half of non-citizen, Spanish-speaking adults agree that they have good communication with their medical practitioner (Kaiser, 2003a). A study conducted by Doty makes the same point. Disparities exist in access to health care, and the language barrier is a contributing factor to accessing health care. Less than half of surveyed Hispanics reported that they always, usually, or sometimes, have a hard time speaking with or understanding their doctor (2003). The overriding concern is only half of those needing an interpreter reported having access 14

(Doty, 2003). Income and Employment. Immigrants tend to be employed at the same rates as citizen populations, but a greater percentage of immigrant families are below the poverty line (Kaiser, 2000b). With a smaller disposable income, immigrant families are forced to reprioritize in order to meet basic needs. Purchasing health coverage does not constitute an immediate need, as food, groceries, rent, and items for children are placed first (Perry et. al., 2000). More than half of the uninsured population are low-income (State Coverage, 2002) and cannot afford coverage, nor do they have the type of job that will provide for coverage. Quinn reports that about sixty percent cannot pay their bills (Quinn, 2000). The Hispanic immigrant population is disproportionately represented in lowincome status groups. Although just as likely to be employed, only forty-three percent of Hispanic immigrants have employer-based coverage. Unfortunately, low-wage workers are less likely to be offered health insurance coverage by their employers (Families, 2001). Schur et. al. (2001) maintains that, as of 1999, Hispanic immigrants working full-time earn less than half the income of a non-hispanic white: $13,000 compared to $27,000. The difficulty of Hispanic immigrants acquiring health coverage is due to the type of work and industries in which they are employed. n-citizens are more likely than their U.S. born counterparts to work in jobs that do not provide insurance coverage to their employees (Schur et. al., 2001). 15

Health Insurance Coverage. The immigrant population continually faces a lack of health insurance coverage. Lack of coverage is due to an array of factors including immigration status, language, and employment. Combining these factors, low-income non-citizens are more than twice as likely to have insurance as low-income citizens. In the United States, of the eleven million low-income non-citizens, sixty percent lack health care coverage (Kaiser, 2003b). Due to the high numbers of immigrants, then combined with low-income status, the magnitude of the problem is evident in the reliance on safety-net facilities for their usual source for health care (Doty & Ives, 2002). The state of Texas relies on safety-net facilities and Medicaid for health care coverage for indigents. State and county tax monies fund these safety-net providers. The counties have an obligation to provide health care for indigents who are legal residents of the counties. Texas counties have historically been responsible for healthcare of legal residents of the county who are medically indigent. This historical pattern has led to wide disparities in definitions of who is indigent, and in definitions of the minimum levels of care that the county is obliged to provide to indigents. Counties have developed widely differing definitions of indigent, with some counties adhering to the state minimum of people whose incomes are less than 25 percent of the federally defined poverty level ($174 per month or $2088 per year for a single person), and who have no more than $1500 in assets to as high as 200 percent of poverty and more generous asset allowances (Fenz, 2000). Tarrant County provides subsidized care for people who are uninsured who live in families with incomes up to $200 of poverty and 16

thus is one of the most generous counties in Texas in terms of providing for health care. Some counties, such as Tarrant County, have well developed safety-net systems that include comprehensive hospital care and geographically dispersed community clinics. Others provide only the state mandated minimum financial support for emergency care. There are three ways for counties to provide indigent healthcare: (1) by creating a hospital district (HD) that can levy taxes to provide hospitals, health clinics, and other programs for indigents; (2) by operating a public hospital (PH) funded at least partially by county funds; and (3) by creating a county indigent health care program (CIHCP) to pay for services received from non-tax funded providers (Fenz, 2000). Tarrant County provides care using the hospital district plan, the most generously funded plan of the three types. Medicaid is also available to residents of Texas but coverage is limited compared to other states (Weiner et. al., 1997). The Texas Department of Insurance states that Medicaid is the second largest source of health insurance in the state (2002), it but still provides health care coverage for less than twenty-five percent of the people in the state with incomes below the federally defined poverty levels. In addition to the disadvantages of low-income status, policy barriers and changes in law further increase the disparity. Inconsistency in Medicaid coverage regulations contribute to lack of coverage, many times only allowing emergency care and not a usual source of care (Kaiser, 2003b). New regulations passed in 1995 were expanded to include coverage to non-citizens, and even undocumented aliens. The cost 17

to the state and the Medicaid program was $440 million, although actual use was calculated at less than one percent of total Medicaid expenditures (Weiner et. al., 1997). Employment-based coverage. The most significant predictor of health coverage is employer-provided insurance. In the state of Texas, over 150 million Texans obtain health coverage through their employer (State Coverage, 2002). Due to the commanding factors of immigration status, language, and income, only twenty-three percent of Hispanic immigrants have job-based insurance. This leaves almost seventyfive percent of Hispanic immigrants completely uninsured (UCLA & Kaiser, 2000). Quinn reports the key reason for such a high rate of uninsured in the Hispanic immigrant population is due to employers not providing health benefits to employees (2000). Lack of coverage is not because of unemployment, but rather the type of employment. The proportion is similar to or exceeds that of other race and ethnic groups (Quinn, 2000). The Kaiser Family Foundation reports the unequal representation of employer-based coverage across ethnic lines. Hispanics are less likely to have employer-provided insurance than whites (Kaiser, 2000d). Nine million of the eleven million uninsured Hispanics are in families where at least one person works (Quinn, 2000); only two-thirds of Hispanic immigrants have job-based coverage compared to that of the white, non-hispanic population (Kaiser, 2000d). UCLA and Kaiser report similar findings adding that Latinos uninsured rate is extraordinarily high because of lack of employment-based health insurance programs. Only forty-three percent of Hispanics have coverage, compared to seventy-five percent of whites. Other ethnic 18

groups are covered at rates between fifty-one and sixty-four percent (UCLA & Kaiser, 2000). Reasons for the disproportionate representation of Hispanics and Hispanic immigrants for health coverage are the types of employment opportunities. Working for small firms places Hispanic immigrants at a disadvantage for obtaining necessary health coverage (Kaiser, 2000d). The Texas Department of Insurance reports that small firms are the primary work places for Hispanics and Hispanics immigrants. This contributes to the high number of uninsured. Nearly one-half of all uninsured workers work for employers with less than twenty-five employees (Texas Department, 2002). Full-year employment status also contributes to the Hispanic immigrants disadvantage in jobbased coverage. Seasonal employment contributes to the high rate of uninsured (UCLA & Kaiser, 2000). Unequal representation exists in health coverage for non-whites and whites in the population. Schur et. al. reports that full-time, Hispanic employees are extended health coverage thirty percent less often than non-hispanic whites (2001). UCLA and Kaiser report that rates of working for an employer that provides health coverage to workers are twice as high for non-hispanics as for Hispanics. As a result, Latinos are much less likely to be insured through their employer at the rate of fifty-three percent (2000). Over half of Texas residents have health coverage provided by their employers (Texas Department, 2002). However, the percentage of Texans who are insured by employer-sponsored health insurance plans is ten percent lower than the national 19

figure. Small businesses extending coverage to employees are fifty percent higher than the national average. Employer contribution on behalf of the employee ranks twentyfive percent higher in Texas than in other states (Sacks et. al., 2002). These findings contribute greatly to the understanding of citizenship status, race, income, and employment as mitigating factors in one s ability to obtain health coverage. Usual Source of Care. Evident in the preceding literature, citizenship, immigration status, language, employment, income, perceived need, and insurance coverage all influence health behavior. Relevant to each predictor variable, findings reveal significant indicators that describe how Hispanic immigrants are at a disadvantage for accessing the health care system. This represents a disadvantaged population that is possibly foregoing necessary medical treatment due to structural obstacles that can be resolved. UCLA and Kaiser support this assertion stating that Hispanics are more likely than any other ethnic group, at twenty-six percent, to have no usual source of health care (2000). Race and ethnicity are very important contributing factors for determining health behavior: half of uninsured Hispanics have not seen a doctor, gotten a needed prescription med, or received necessary tests (2000). Forty-nine percent Hispanic families have no usual source of health care. Instead of relying on physician services, the emergency department or neighborhood clinic is the primary source of care (Families, 2001). Immigrant status actually increases the likelihood of going to the emergency department as the regular source of care (Kaiser, 2000a). Difficulties seeking care and obtaining care influence one s behavior in meeting 20

health needs. Spanish-speaking populations have greater difficulty accessing health care than English speaking populations (Doty, 2003). Insurance coverage remains the greatest barrier to care, as many individuals forego care due to cost and accessibility. Kaiser reports that having coverage, private or public, increases potential for having a usual source of care (2000d). Having insurance minimizes the effects of ethnicity (Kaiser, 2000d). State Coverage (2002) confirms that the uninsured are less likely to have a regular source of care and also a recent doctor visit. Perry et. al. reports that uninsured populations indicate cost as the most significant factor in determining access to health care. Because of cost, free/low-cost health clinics and doctors are the ultimate source, next to the emergency department (2000). Implications are such that one s individual health, family health, and the health of the community are jeopardized. The financial burden rests upon health care providers and public entities to provide care. This many times constitutes greater costs to the healthcare provider as individuals have delayed care resorting emergency services or hospital visits. Need. Subjective indicators of need measure perceived health status (Gelberg, Andersen, and Leake, 2000). Research indicates that Hispanics are less likely to report a health condition yet more likely to report fair or poor health (Doty & Ives, 2002). The Commonwealth Fund supports the same position, stating that minority adults are more likely (24 percent) to report poor health (Commonwealth, n.d.) than Anglos. These findings may represent cultural differences in perception of health. 21

Also relevant to perceived health need, some gender differences exist. Hispanic males report fair or poor health twice as often as females. Twenty-five percent of males, compared to thirteen percent of women, forego doctor visits due to perceived need. Forty percent of uninsured Hispanic men in fair or poor health have not seen a doctor in the last year (UCLA & Kaiser, 2000). Health insurance for men is twice the rate for women (UCLA & Kaiser, 2000), however they are not accessing the health care system at the same rates. Perceived need is higher for males than females, yet access is less. Each of these indicators produces health outcomes. UCLA and Kaiser report perceived need as a predictor for health behavior (2000). Level of perception in overall health does in fact affect the probability of a doctor visit (2000). Summary Studies relevant to access to health care suggest that Hispanic immigrants are disproportionately represented in the population that has difficulty accessing care. They experience a double burden with a lack of health coverage and also with employment opportunities. Hispanic immigrants suffer from additional adversity in accessing the health care system due to race/ethnicity, linguistic barriers and citizenship status. Subsequent steps are to reduce or even eliminate barriers for Hispanic immigrants. The reduction in barriers to the health care system will reduce the disparities in health in the United States. Research does identify poverty as a significant predictor of access to health care and coverage. Since the proportion of Hispanic Immigrants are characterized as poor or 22

near poor, and considering the private pay health care coverage system in the United States, attaining health coverage for Hispanic immigrants remains far beyond their reach. Disparities between Hispanic and non-hispanic white populations are reinforced in the structures of the health care system. Access is granted based on these structures. Language barriers, employment, citizenship status, income, language and translation, type, or lack of coverage, all contribute to the factors that determine access to the health care system. These are also the same forces that act as impediments to vulnerable populations resulting in the high-uninsured rate of non-citizens. The Texas Department of Insurance references The American Journal of Public Health from June, 2000, on the low-status, low-income employment opportunities that are available to Hispanic immigrants (2002). Hispanics tend to be employed by firms that do not extend coverage to employees, and this lack of employer coverage explains the high rate of uninsured among the Hispanic immigrant population (Texas Department, 2002). Lack of access to health care influences overall health behavior as individuals, families, and children often forego necessary health care. This behavior potentially exposes communities to unnecessary health risks. Doty and Ives report the manifestation of such behaviors in health outcomes. Hispanic immigrants struggle to receive needed health care and are partially influenced by the inability to establish consistent care with healthcare providers. This behavior is due, in part, to the difficulties encountered upon entering the system (Doty & Ives, 2002). Policy adjustments are necessary to reduce those structural barriers to care that will allow for the elimination of disparities in health in the United States. 23

CHAPTER 2 METHODOLOGY Introduction The following chapter describes the research design and statistical methods used in analyzing the sample population and also in reaching the eventual conclusions. This chapter also explains the population and sample, survey instrument, research design, statistical analysis, and the operational measures of the variables in regard to reliability and validity. Reliability ensures the consistency of results, while validity represents the accuracy of measures (Babbie, 1998; Patten, 2000). The frequencies of each variable are also described in this chapter, as well as the potential limitations of this study. Population and Sample Secondary data were collected about behaviors and attributes of Hispanic immigrants in a sample of low-income, working-age adults, ages 18-60 years, who use health care services provided by John Peter Smith (JPS) Health Network and associated community clinics in Tarrant County, Texas. Data were collected from a random sample of 2,034 clients who used services in July and August of 2000. The original list of 10,000 clients reflected the multi-racial, multi-ethnic population of Anglos, African- Americans, Hispanic Americans, Hispanic immigrants, Asian-Pacific Islanders, and American Indians. The population also reflected the varied health insurance status groups including those privately insured, uninsured, publicly insured either through Medicare or Medicaid, JPS Connections, CHAMPUS, TRI-CARE, military health care--or VA--as well as other sources. The Hispanic immigrant sub-sample of N=379 is the 24

focus of this study. The payment office of the JPS Health Network provided the patient lists of all patients seen in the health care network during these two months. The CATI system was used to randomly select patients to be interviewed. Individuals in the sample were called five times, varying days and times, before being dropped for another potential respondent (Eve et. al., 2001). Strengths and Limitations of the Population Sample Design. As with any sample design, advantages and limitations exist within this sampling methodology. This particular methodology reflects its own inherent probability sampling strengths. It allows the sample to be representative of the JPS population, to include all of the mixed characteristics of race, ethnicity, and access to health care. Having a large sample size (Babbie, 1998) allows for a large degree of representativeness of the sample (Babbie, 1998; Friis and Sellers, 1999; Pyrczak, 1995), this reduces the possibility of sample error, thereby increasing the validity of the study. A strength in this sample design is the residence of respondents being from one county, Tarrant County, so that the questions can be designed for the local population. Furthermore, the principal investigators (PIs) who initiated and conducted the primary study have lived and worked in Tarrant County and the vicinity for many years, and are familiar with the sample population. They each hold additional and helpful insights to the population that may not otherwise be present in someone from outside the area. Research Design This study is a secondary analysis of the data collected by Eve et. al. (1999). The original study was conducted to answer the following questions arising from the health 25

care system: 1) What is the effect of those health care reforms on the ability of the low income workforce in Texas to access and use the health care system when they are sick. 2) What is the effect of this on the cost on their health care? 3) What is the health status of the client/patient population (Eve, Koelln, Trevino, and Bauman, 1999)? Data were collected for the purpose of achieving three objectives: 1) to assess access to healthcare, 2) economic costs of care and lack of care, and 3) health status of prime working-age (18-55 years), low income (less than 200 percent of poverty), adult residents of Tarrant County, Texas (Eve, Koelln, Trevino, and Bauman, 1999). A closed-ended, multiple-choice, questionnaire was used to collect the primary data. The questionnaire was comprised of nine main sections. The nine sections covered are as follows access to care, getting health care from a specialist, no usual source of care for sick care, insurance, unmet needs, health care in the last twelve months, background information, which included socio-demographic variables, immigration status, and a final section evaluating for women s health. The final section was administered to women only. The University of rth Texas Survey Research Center administered the survey. The Center used the Computer Assisted Telephone Interviewing (CATI) methodology. The CATI system randomly selects and dials telephone numbers programmed into a central computer (Babbie, 1998). Reliability and Validity of the Questionnaire. This questionnaire was based on standardized questions from the National Health Interview Survey (NHIS). Revisions 26

were made to meet the needs of the local community, Tarrant County, Texas, where the data were collected. The benefit of using the interview survey methodology in the original study is that it is a standardized, pretested questionnaire that is reliable and valid. The strength of the measurement in survey interviews improves the reliability of the study (Babbie, 1998), and by using a standardized, pretested questionnaire, the same questions were asked of all the participants, with the same motivation for each respondent. Also, contributing to the validity of the measurement, adapting the questions to the local community attempts to capture the conditions of the area. This improves both the content validity and general validity of the questionnaire (Babbie, 1998). Using the trained interviewers to administer the questionnaires increased reliability. Use of the random dialing technique from the list of JPS patients increased the validity. Since communication is not face-to-face, the probability of the interviewee being influenced to give a more socially desirable answer is less likely (Babbie, 1998). Although there are advantages to using the CATI survey interview technique, there are also weaknesses and limitations to the method. Those limitations do reduce the external validity of this particular study and the ability to generalize on the larger patient base of the John Peter Smith safety-net Health Network clients due to the sampling technique. The sample was acquired from the population of patients who used health care at JPS in July and August of 2000; therefore, it is the only aspect of the study worthy of criticism because it is summer vacation for students, and those on the 27

patient list may or may not be at home. Those individuals may not necessarily represent the general population who uses health care services at JPS. A further weakness of the closed-ended standardized questionnaire is the inherent inflexibility of the technique and method. Babbie (1998) explains, By designing questions that will be at least minimally appropriate to all respondents, you may miss what is most appropriate to many respondents. In the sense, surveys often appear superficial Similarly, survey research can seldom deal with the context of social life. Considering these weaknesses, this type of method deprives data of possible relevant background information that could possibly provide additional insight or depth to the situation. Strengths and weaknesses of the data collection design. One of the greatest strengths of the study is the use of a random sample method; however, this method does allow for the data results to be susceptible to random errors. In order to offset the influence of the method, the alpha level was set at a conservative.05. This ensures that the probability of encountering a Type I decision, or a wrong decision, is minimized. With a sample size of this magnitude the possibility of a sampling error is minimized (Babbie, 1998). The inherent strengths and weaknesses of the data collection design will contribute to the empirical outcomes of this study. netheless, being original data and being constructed according to the guidelines of the NIHS for the design of the study and the technological strengths including wording and material of the questionnaire (Babbie, 1998), the survey retains its validity. In addition, the 28

administering professionals in the original study are highly qualified respected professionals who combined their skills and expertise for collecting the data. The interview method used to conduct this research and collect the data is also a strength. As previously mentioned the telephone system, for administering surveys, has higher survey completion rates and has fewer incomplete and misunderstood results. However, the possibility does remain that the telephone number was given for a neighbor or a friend, thereby reducing risk of someone not being able to be reached. The interviewer is able to pursue the interviewee to obtain an answer and is also available to answer any questions for clarification that the interviewee may need answered. Aside from limiting responses to only those individuals with a telephone as well as increasing the incidence for social bias and/or having socially desired responses, this method is especially good for reliability and validity issues considering that the alternative is having the questions left unanswered, as in a self-administered test. Other strengths are the standardization and pretesting of the questionnaire before the final data collection. An additional factor, and the one related to this particular study, is the language for barrier Hispanic immigrants. Interviews were conducted in Spanish, thereby allowing respondents to speak in their native language. Although, the study methodology has many strengths it also has some weaknesses. By nature of the study and the retrospective research methodology, there may be recall bias. Cross-sectional studies seek to understand casual processes over time; however those causal processes are based on observations made only during one 29